NEPHROLOGY 2

CHRONIC KIDNEY DISEASE (CKD)

A 56-year-old female presents to the clinic with a history of increasing fatigue and generalized
weakness over the past several months. She also reports experiencing decreased appetite,
unintentional weight loss, and occasional nausea. She mentions feeling more thirsty than usual
and having to wake up at night to urinate. She denies any recent illnesses or significant changes
in her lifestyle. Her medical history includes hypertension, which has been managed with
medication for the past five years. She mentions that her blood pressure has been more difficult
to control lately, despite taking her medications regularly. She denies any history of diabetes or
other chronic conditions. She has no known drug allergies. Her family history is unremarkable,
with no known history of kidney disease or other significant medical conditions. She is a
nonsmoker and does not consume alcohol regularly.
a)what is mostly likely diagnosis and why
b)what investigations are to be done
c)what is appropriate treatment for this patient.

a) Based on the patient's presentation, the most likely diagnosis is chronic kidney disease (CKD).
The patient's symptoms, including fatigue, weakness, decreased appetite, unintentional weight
loss, nausea, increased thirst (polydipsia), and nocturia (waking up at night to urinate), are
consistent with the clinical manifestations of CKD. The presence of hypertension, which has
been difficult to control, is also a common risk factor for CKD.

b) The following investigations should be considered to further evaluate the patient:

A complete blood count (CBC): may reveal anemia which is commonly associated with CKD.
Kidney function tests: such as serum creatinine and estimated glomerular filtration rate (eGFR),
can assess the level of kidney function.
Electrolyte levels: to identify hyperkalemia, acidosis
Urinalysis can provide information on proteinuria (excess protein in the urine) and the presence
of red or white blood cells which may indicate the cause of the disease
Imaging: A renal ultrasound may be ordered to assess the size, shape, and structure of the
kidneys and detect any abnormalities, such as cystic kidney
Lipid profile: cardiovascular risky is high in CKD
ECG: may show changes such as increase PR interval due to effect of potassium in conducting
system of the heart
Hepatitis and HIV serology: if dialysis or transplant is planned
Parathyroid hormone and vitamin D: assessment of the renal osteodystrophy

some general principles of CKD management include:

Blood pressure control: Given the patient's hypertension and difficulty in blood pressure
management, aggressive blood pressure control is important. Lifestyle modifications and
antihypertensive medications, such as angiotensin-converting enzyme (ACE) inhibitors or
angiotensin receptor blockers (ARBs), may be prescribed.
Diabetes management: If the patient has underlying diabetes, optimal glycemic control is
essential to slow the progression of CKD.
Hyperkalemia: If hyperkalemia occurs, drug therapy should be reviewed to reduce or stop
potassium sparing diuretics, ACE inhibitors and ARBs.
Dialysis: may be done to correct electrolyte imbalance and uremia
Dietary modifications: A low-sodium, low-protein diet may be recommended to reduce the
workload on the kidneys.
Lipid lowering therapy: hypercholesterolaemia is almost universal in patients and increased
triglyceride levels are common in patient with CKD. ezetimibe and simvastatin has proved to
reduce major atherosclerotic event in patient with CKD
Treatment of anemia: anemia is common in GFR below 30ml recombinant human
erythropoietin is effective in correcting the anemia
Renal bone disease: treatment should be initiate with active vitamin D metabolites calcium
hyperparathyroidism may be treated by calcium mimetic such as cinalcet which bind to calcium
sensing receptor and reduce parathyroid secretion
Hyperphosphatemia should be treated by;
§ Dietary restriction of foods with high phosphate content (milk, cheese, eggs )
§ The use of phosphate binding drugs (calcium carbonate, aluminum hydroxide,
lanthanum carbonate)

CASE 2
An 85-year-old woman is investigated by her general practitioner (GP) for increasing tired- ness
which has developed over the past 6 months. She has lost her appetite and feels constantly
nauseated. She has lost about 8 kg in weight over the past 6 months. For the last 4 weeks she
has also complained of generalized itching and cramps. She has been hyper- tensive for 20 years
and has been on antihypertensive medication for that time. She has had two cerebrovascular
accidents which have limited her mobility. She is an African- Caribbean, having emigrated to the
UK in the 1960s. She lives alone but uses a ‘meals on wheels’ service and goes to a day hospital
twice a week. She has two daughters.
what is most likely diagnosis and why

based on the provided information, the most likely diagnosis for the 85-year-old woman is CKD .
Several factors support this diagnosis:
Progressive Fatigue, Weight Loss, and Nausea: These symptoms are commonly seen in CKD as a
result of poor appetite, accumulation of waste products, electrolyte imbalances, and metabolic
disturbances.
Generalized Itching and Cramps: These symptoms can occur due to the buildup of toxins in the
blood, such as uremic toxins, which are not effectively eliminated in renal failure.
Hypertension and Long-standing Antihypertensive Medication Use: Hypertension is a known risk
factor for the development of chronic kidney disease (CKD) and can progress to ESRD over time.
The patient's history of hypertension for 20 years and long-term antihypertensive medication
use increases the likelihood of renal involvement.
Limited Mobility and African-Caribbean Ethnicity: Reduced mobility and African-Caribbean
ethnicity are associated with an increased risk of developing CKD.
Advanced Age: CKD is more prevalent among older individuals, and the patient's age of 85
increases the likelihood of renal impairment.
investigations

Serum creatinine and blood urea nitrogen (BUN): Measure renal function and the degree of
impairment.
Complete blood count (CBC): Assess for anemia and other blood abnormalities.
Electrolyte panel: Check for electrolyte imbalances, particularly potassium and calcium levels.
Serum albumin and total protein: Evaluate nutritional status.
Urinalysis: Examine for proteinuria, hematuria, and urinary sediment abnormalities.
Renal ultrasound: Assess kidney size, structure, and detect any obstructions or abnormalities.
Renal Doppler or CT scan: Evaluate renal blood flow and identify any vascular abnormalities or
renal artery stenosis.
Viral serologies: Screen for hepatitis B and C, as these infections can contribute to kidney
disease.
Autoimmune markers: If indicated based on clinical suspicion, test for antinuclear antibodies
(ANA) and anti-glomerular basement membrane (anti-GBM) antibodies.
Treatment
Symptom Management
Address the patient's symptoms of fatigue, nausea, itching, and cramps through supportive
measures, such as dietary modifications and medications to alleviate symptoms (e.g.,
antiemetics, antipruritic(antihistamines), and phosphate binders).
Blood Pressure Control
Optimize blood pressure control using antihypertensive medications, aiming for target blood
pressure levels specific to the patient's age and comorbidities. Consider medications like
angiotensin-converting enzyme inhibitors (ACE inhibitors) or angiotensin receptor blockers
(ARBs) with proven renal benefits.
Nutritional Support
Collaborate with a renal dietitian to develop an individualized diet plan, considering the
patient's nutritional needs, fluid and electrolyte balance, and restrictions related to renal
function.
Renal Replacement Therapy (RRT)
Discuss the option of renal replacement therapy with the patient and family members. This may
include hemodialysis, peritoneal dialysis, or consideration for kidney transplantation. The choice
of RRT modality depends on various factors, including patient preference, clinical condition, and
availability of resources.
Management of Comorbidities
Optimize management of other medical conditions, such as diabetes and cardiovascular
disease, with appropriate medications, lifestyle modifications, and regular follow-up.
Supportive Care:
Regular monitoring of renal function, fluid and electrolyte balance, blood pressure, and
nutritional status.
Collaboration with a multidisciplinary team, including nephrologists, dietitians, social workers,
and pharmacists, to provide comprehensive care and address the patient's physical and
psychosocial needs.

What are signs of renal failure during generation examination

ACUTE KIDNEY INJURY(AKI)

A 53 year old man presented to the emergency department with 3 day history of oliguria and
nausea. Is a known diabetic and hypertensive patient for 7 and 4 years respectively. He takes his
medications irregularly. On examination, he appeared sick, temperature 37°C, pulse rate
123beats/min, respiratory rate 20breaths/min, blood pressure 150/95mmHg and peripheral
oxygen saturation 87% on room air. He had an altered mental status. The following
investigations were done with respective results; Full blood picture: essentially normal,
urinalysis: protein (++), random blood glucose: 13mmol/l, serum sodium: 140mEq/L, serum
potassium: 5.6mEq/L. From this information; a
a. What do you consider to be the most likely diagnosis and why?
b.With justification explain how would you manage this patient

Based on the provided information, the most likely diagnosis for this patient is acute kidney
injury (AKI). The presence of oliguria (reduced urine output), nausea, altered mental status for
short duration indicates AKI

the patient is to be stabilized fast

A. Airway: Assess and ensure the patient's airway is patent and provide necessary interventions
if there are any signs of airway compromise.

B. Breathing: Assess the patient's respiratory rate, effort, and oxygen saturation. Administer
supplemental oxygen to maintain oxygen saturation above 92%. Monitor the patient's
respiratory status closely.

C. Circulation: Evaluate the patient's blood pressure, heart rate, and peripheral perfusion. Start
intravenous access and administer fluid resuscitation as needed to maintain adequate blood
pressure and perfusion. Correct any electrolyte abnormalities, such as hyperkalemia, as
mentioned earlier.

D. Disability: Assess the patient's neurological status, including level of consciousness and
Glasgow Coma Scale (GCS) score. The patient's altered mental status warrants immediate
attention. Consider possible causes such as uremia, electrolyte imbalances, or other
complications of AKI. Address the underlying cause and provide appropriate treatment.

E. Exposure: Undress the patient and perform a thorough physical examination, focusing on
potential signs of infection, rashes, or trauma. Look for any evidence of urinary tract
obstruction, which could contribute to AKI. Consider performing a bladder scan or renal imaging
studies if obstruction is suspected.

Investigation to be done
Renal Function Tests: Serum creatinine and blood urea nitrogen (BUN): These tests provide
information about kidney function and the degree of impairment.

Estimated glomerular filtration rate (eGFR): Calculating the eGFR helps assess the severity of
kidney dysfunction.
Urinalysis: Assess for the presence of red blood cells, white blood cells, proteinuria, casts, and
other abnormalities. This helps differentiate prerenal and intrinsic renal causes of AKI.
FBP: leukocytosis incase of infection, low platelets in case of DIC
Renal Imaging:
Renal ultrasound: A non-invasive imaging test to assess kidney size, identify any structural
abnormalities, and evaluate for urinary tract obstruction.
CT scan or MRI: These imaging modalities may be considered if a renal ultrasound does not
provide sufficient information or if there is suspicion of a specific etiology (e.g., renal artery
stenosis or renal masses).
Chest Xray: Pulmonary edema is common in AKI
Autoimmune and Infectious Workup:
Antinuclear antibody (ANA), complement levels, and anti-glomerular basement membrane
(anti-GBM) antibodies: These tests may be ordered if there is suspicion of an autoimmune
cause of AKI, such as lupus nephritis or rapidly progressive glomerulonephritis.
Serology for hepatitis B and C, HIV, and other infectious causes: Infections can sometimes lead
to AKI, and identifying the underlying infectious etiology is important.
Urine and Blood Cultures
Obtain cultures to assess for the presence of urinary tract infection or bloodstream infection,
which can contribute to AKI or complicate management.
Kidney Biopsy
A kidney biopsy may be considered in specific cases where the etiology of AKI remains
uncertain, and the information obtained would guide management decisions.

NOTE: not all above investigation will done on the same occasion

Treatment
Fluid and Electrolyte Management:
 Administer intravenous fluids cautiously to achieve euvolemia, balancing the need for
adequate renal perfusion while avoiding fluid overload.
 Monitor and correct electrolyte imbalances, such as hyperkalemia, hyponatremia, or
metabolic acidosis, as indicated.
Management of Underlying Conditions:
 Optimize glycemic control in the patient's diabetes through insulin therapy and
appropriate medication adjustments.
 Control blood pressure, especially in hypertensive patients, using antihypertensive
medications to achieve target blood pressure levels.
 Address any other contributing factors or comorbidities, such as infections or
medication-related nephrotoxicity.
Avoid Nephrotoxic Agents:
 Identify and discontinue any potentially nephrotoxic medications whenever possible.
This may include certain antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs), or
contrast agents.
Supportive Care:
 Monitor vital signs, urine output, and fluid balance closely to guide fluid management.
 Provide adequate nutritional support and monitor the patient's nutritional status.
 Address complications such as anemia, electrolyte abnormalities, or acid-base
imbalances as needed.
  Prevent and manage complications related to immobility, infection, or thromboembolic
events.
Renal Replacement Therapy (RRT):
 Consider initiating renal replacement therapy, such as hemodialysis or continuous renal
replacement therapy (CRRT), in severe cases with refractory fluid overload, severe
electrolyte disturbances, or signs of uremia. Consultation with a nephrologist is essential
to determine the optimal timing and modality of RRT

CYSTIC DISEASE OF THE KIDNEY

A 46-year-old woman presents to the emergency department with a 2-day history of right-sided
loin pain and macroscopic hematuria. The pain is continuous and dull in character. Over the past
10 years she has had previous episodes of loin pain which have occurred on both sides and
resolved spontaneously over a few days. She has never passed any stones. She was noted to be
mildly hypertensive during her three pregnancies. She has no other significant medical history.
Her father died of a subarachnoid hemorrhage, aged 48 years. Her father’s brother has had a
kidney transplant. She has no siblings. Her three children, aged 17, 14 and 10 years, are well.
She works as a teacher and neither smokes nor drinks alcohol.
Examination
On examination she is afebrile. Her pulse is regular at 76/min and her blood pressure is
135/105mmHg. Examination of the cardiovascular and respiratory systems is otherwise
unremarkable. On palpation of her abdomen, ballotable masses are palpable in each flank. The
right-sided mass is tender to palpation. Percussion note is resonant over the masses.
Neurological examination is normal. Fundoscopy shows arteriovenous nipping and silver- wiring
of the retinal vessels.

a)what is the most likely diagnosis and why

b)how will you manage the patient

Based on the provided information, the most likely diagnosis is Autosomal Dominant Polycystic
Kidney Disease (ADPKD).

b) Justification for the diagnosis:

Clinical Presentation: The patient's history of recurrent episodes of loin pain over several years,
along with the presence of macroscopic hematuria, is consistent with the characteristic
manifestations of ADPKD.
Family History: The patient's father's early death due to a subarachnoid hemorrhage and her
paternal uncle's kidney transplant suggest a familial condition, supporting the possibility of
ADPKD, which is inherited in an autosomal dominant manner.
Hypertension: The patient's history of mild hypertension during pregnancies is also a common
finding in ADPKD. Hypertension can occur due to the activation of the renin-angiotensin-
aldosterone system and compression of renal blood vessels by cysts.
Abdominal Examination: The palpable bilateral flank masses, tenderness on the right side, and
resonant percussion note are consistent with the presence of enlarged kidneys due to multiple
cysts.
Ophthalmic Findings: The retinal changes observed, including arteriovenous nipping and silver-
wiring of retinal vessels, can be seen in patients with hypertension and chronic kidney disease,
both of which are commonly associated with ADPKD.

Investigations

Renal Ultrasound: This imaging study is commonly performed to confirm the presence of
multiple renal cysts and assess their size and distribution.
Genetic Testing: Genetic testing for mutations in the PKD1 and PKD2 genes can be considered to
confirm the diagnosis of Autosomal Dominant Polycystic Kidney Disease (ADPKD). However, it
may not be necessary for the diagnosis if clinical features and family history strongly support
the diagnosis
Complete blood count (CBC): To assess for anemia and other blood abnormalities.
Renal function tests: Including serum creatinine, blood urea nitrogen (BUN), and estimated
glomerular filtration rate (eGFR) to evaluate kidney function.
Urinalysis: To assess for proteinuria, hematuria, and urinary tract infections.

Pharmacological Treatment
Blood Pressure Control:
Antihypertensive Medications: The choice of antihypertensive drugs depends on individual
patient characteristics. Medications commonly used in ADPKD include ACE inhibitors,
angiotensin II receptor blockers (ARBs), and diuretics. These medications help control blood
pressure and can also slow the progression of kidney disease.
Pain Management:
Nonsteroidal Anti-inflammatory Drugs (NSAIDs): NSAIDs may be used for the management of
pain in ADPKD. However, caution should be exercised as long-term use can potentially worsen
renal function. Therefore, their use should be limited and monitored by a healthcare
professional.
Other Analgesics: Depending on the severity of pain, other analgesics such as acetaminophen
or opioids may be considered under the guidance of a healthcare professional.
Non-Pharmacological Treatment
Lifestyle Modifications:
Dietary Changes: A low-sodium diet is recommended to help control blood pressure and reduce
fluid retention. A healthcare professional or dietitian can provide specific dietary
recommendations.
Regular Exercise: Engaging in regular physical activity can help maintain overall health and
manage blood pressure. However, exercise should be done under the guidance of a healthcare
professional, considering the patient's individual capabilities and limitations.
Surveillance and Monitoring:
Regular Follow-up Visits: Regular monitoring of renal function, blood pressure, and disease
progression is essential. The frequency of follow-up visits will depend on the individual patient's
condition and stage of disease.Imaging Studies: Periodic renal ultrasound or other imaging
studies may be performed to monitor the size and growth of renal cysts and assess any
complications.

Supportive Care:Genetic Counseling: Genetic counseling should be offered to the patient and
family members to discuss the inheritance pattern, risks, and family planning options.